The Patient Safety and Quality Improvement Act of 2005, signed by President George W. Bush, will promote cultures of safety across healthcare settings by establishing federal protections that encourage thorough, candid examinations of the causes of healthcare errors and the development of effective solutions to prevent their recurrence. Previously, evaluative information about the underlying causes of adverse events was not always considered confidential or protected from lawsuits, a fact that the
This bill is a breakthrough in the blame and punishment culture that has literally held a death grip on healthcare, says Dennis S. OLeary, M.D., president of Joint Commission. When caregivers feel safe to report errors, patients will be safer because we can learn from these events and put proven solutions into place.
Since first encouraging similar legislation in 1997, the Joint Commission and other healthcare and patient safety advocates have testified on numerous occasions before Congressional Committees to urge passage of a comprehensive patient safety bill. Major opportunities to improve patient safety can be created by providing caregivers the same types of legal protections long available to airline pilots and air traffic controllers, the Joint Commission and other stakeholders have testified.
The Patient Safety and Quality Improvement Act of 2005 provides full federal privilege to patient safety information that is transmitted to a Patient Safety Organization. The Joint Commission expects to create or become part of a Patient Safety Organization under the auspices of its new International Center for Patient Safety and seek federal approval under a new process to be created by the Department of Health and Human Services. As the nations leading evaluator of healthcare quality and safety, the Joint Commission maintains one of the nations most comprehensive voluntary reporting systems for serious adverse healthcare events and their underlying causes.
Continuing analyses of the underlying causes of adverse events that have been reported to the Joint Commissions Sentinel Event Database permits the Joint Commission to regularly alert the healthcare community to potential patient safety dangers and provide recommendations regarding preventive solutions. However, the number of adverse event reports submitted to the Joint Commission each year represents a small fraction of the actual number of adverse events that experts estimate occur each year.
Medical errors and the unfortunate events that ensue are devastating for patients and their families, the caregivers involved and healthcare organizations, says OLeary. But punishment for these mistakes does not lead to the behavioral and systems changes that are necessary to prevent similar errors from occurring in the future.
In return for federal action on this issue, the Joint Commission believes that the American public should expect significant increases in the surfacing of errors and their causes and the sharing of patient safety solutions. The Joint Commission, which accredits more than 15,000 healthcare organizations, will be in a unique position to gauge the actual impacts of the new legislation by virtue of its continuing on-site reviews of these organizations. In particular, it will become readily apparent as to whether healthcare organizations have truly adopted cultures of safety that constructively encourage medical error and adverse event identification and reporting and the development of appropriate internal solutions.
Source: Joint Commission on Accreditation of Healthcare Organizations